The role of women in the military is changing. Whereas they may have acted as support personnel in earlier conflicts, they now play an active part in combat support and counterinsurgency operations.1 As of September 2010, there were 208,271 women on active duty in the U.S. Army, Navy, Marine Corps and Air Force, representing 14.6% of total military personnel. Data were not available on the proportion of the more than 200,000 military personnel stationed in and around Iraq and Afghanistan on this date who were women.2 Health care for women in the military has traditionally focused on reproductive needs and has not typically addressed military-specific health risks and their outcomes.1

The Challenge of Menstruation during Deployment

Although there are indications that menstruation is problematic for military women who have been deployed, until recently, there has been relatively little research on menstruation in this environment or use of continuous contraception to manage it.

A study published earlier this year indicated that, even when military women have a strong desire for menstrual suppression (66 percent of 500 respondents to a survey), only 21 percent reported using continuous combination oral contraceptives (COCs) to achieve it. The difficulty of compliance with the daily pill regimen was one reason for the lack of use of COCs, according to the authors, who recommended more education on the topic.3

An earlier study to document menstrual experiences and awareness of menstrual suppression during deployment was done in 2007 by Lt. Col. Lori L. Trego, PhD, CNM, Chief of PRMC Nursing Research Service in Honolulu. The data collected from nine in-depth interviews generated several specific underlying themes.4

•Menses are intensified during deployment.

During deployment, menses was irregular and heavy, and symptoms (e.g., cramps, flow, odor, emotional lability, premenstrual syndrome [PMS], fatigue and pelvic fullness) were magnified. Women supplied their own remedies (eg, ibuprofen, acetaminophen/caffeine/diuretic medications) to self-treat menstrual symptoms. They attributed their changes in menstruation to the heat and stress experienced during deployment.

•It is hard to take care of yourself during your period.

The participants reported difficulties in maintaining both personal and menstrual hygiene in the deployed environment. Job factors (eg, physical activity, wearing the uniform and equipment, and military tasks) complicate menstrual hygiene.

•Menstrual challenges include heat, dirt, and portable toilets.

Sand, dirt, heat, and sweat in the deployed environment proved problematic for menstrual hygiene. Heat was a major problem, causing general discomfort during menstruation and problems with the use of menstrual products. For example, adhesive pads do not adhere well to underpants when a woman is hot and sweating heavily. Hygiene practices were dependent on the type of latrine facilities available. Most women had to use port-a-potties during the day, which presented challenges due to the cramped space and lack of sanitation.

•Menstruation is an inconvenience when you are deployed.

Menstruation causes a hassle in the daily lives of women during deployment. Issues include not having enough time to change menstrual hygiene products and the preplanning required to manage menses throughout the day, which, when it fails, can result in leaking and staining. Convoys represent a particularly difficult challenge because women might be in a vehicle for eight straight hours, making hygiene difficult. Preplanning for menstruation while on duty included carrying extra pads, tampons, baby wipes, plastic bags, and hand sanitizer.

•Dealing with menstruation is difficult in the military world where women are a minority.

Most of the women surveyed felt that the men in their unit did not understand menstrual-related issues such as PMS. They could only talk to other women in their unit, for support about menstrual issues.

•The negative aspects of menstruation outweigh the positive during deployment.

Three of the surveyed women expressed their belief that menstruation is a natural, healthy occurrence. However, eight of the nine participants emphatically stated that there were no positive aspects to menstruation during deployment.

Menstrual Suppression

The last of the themes to emerged in the small survey conducted by Trego had to do with menstrual suppression. Seven of the nine military women surveyed were aware that hormonal contraceptives could be used to suppress menstruation. The concerns they voiced about both injectable contraception and continuous-use COCs included side effects, especially during deployment, the safety of continuous-use COCs and problems associated with missing pills. They were especially worried about possible emotional changes and weight gain associated with using hormonal contraceptives. Their level of interest in trying menstrual suppression ranged from none to a willingness to try it for one year. Trego concluded that women in the military should be provided with education on menstrual hygiene and methods of menstrual-cycle control prior to deployment.4

Col. Cathy Nace, MD, FACOG, Deputy Commander of Education at Walter Reed Army Medical Center in Washington, commented that the concept of menstrual suppression is not new but has been employed by gynecologists and providers of women’s health services for many years. “It is not known whether women are routinely informed about the option of menstrual suppression prior to deployment,” she said, “since large-scale patient and provider surveys have not been done.”

Smaller surveys continue to support the fact that menstruation can be problematic during deployment and that women in the military are requesting more education. When Trego and Jordan later surveyed 278 women in the U.S. Army with deployment experience, they found that although the group was generally neutral about menstruation, they favored menstrual suppression during deployment because of the effects of stress on their periods, the barriers to menstrual hygiene during deployment, and the potential benefits of suppression. The investigators concluded that women being deployed should be educated on the benefits and risks of menstrual suppression methods and be informed of the potential impact of deployment on their menstrual experiences.5 Several surveys conducted by Powell-Dunford and colleagues have had similar findings. The majority of military women who were surveyed favored menstrual suppression during deployment, but only a small percentage had actually used this method.6,7 The recent post-deployment survey of 500 women found that two-thirds of the group had problems taking a COC daily; however, continuous COC users were almost twice as compliant as conventional COC users (P=0.019), and compliant users reported significantly less menstrual burden than noncompliant users (P=0.017). As in earlier surveys, the vast majority of women surveyed expressed a desire for mandatory education about menstrual suppression using COCs.3

The LNG-IUS represents a possible approach to inducing reversible amenorrhea in women who have problems taking daily pills. It is important to recognize that amenorrhea does not occur in all women using the LNG-IUS. Although the prescribing information for the Mirena® LNG-IUS states that 23.9% of users became amenorrheic,8 other studies have shown higher percentages of amenorrheic users at six months.9 Trego is designing a study to look at the use of alternate forms of menstrual-cycle control during deployment.

In the Future…

The need for more consistent education about menstrual suppression is a continuing theme in these surveys. Trego commented that the characteristics affecting the attitudes of women about menstrual suppression during deployment have been found to include the physical features in the environment (e.g., dirt, dust, sandstorms, temperature extremes and rudimentary facilities), the types of military duties and menstrual hygiene activitiesin which they are participating and the role they play in that setting, i.e., whether they are functioning in a nurturing capacity or as fighters. She has pilot-tested a new Women’s Health Deployment Program developed by her and her colleagues for use in the military.

“This 30-minute structured pre-deployment education program includes contraception, the causes and prevention of infections, and the menstrual cycle—what affects it and options for regulating and/or suppressing it,” she explained. Trego and her team have already gained the support of a large unit in Hawaii for the program. Her hope is that it will ultimately be acculturated into the routine preventive health care for all women in the military.

Note: Comments made by Lt. Col. Trego and Col. Nace reflect their personal opinions and do not represent the views of the Department of the Army, the Department of Defense, or the U.S. government.